State Medicaid Benefits and Availability of Substance Use Disorder Services

Background and Purpose: The Affordable Care Act (ACA) dramatically expands health insurance for substance use disorder (SUD) treatment. Yet, because it also allows substantial flexibility for state governments—both in terms of whether to expand Medicaid coverage up to 138% of poverty and in terms of what particular SUD services to cover under their Medicaid programs—there is likely substantial variation in the types of SUD services to which people have access across the United States. The purpose of this paper is to better understand how Medicaid SUD coverage policies vary across the 50 states, and how variation in coverage is related to SUD treatment organizations’ acceptance of Medicaid enrollees.

Methods: To collect data on Medicaid benefits for SUD services, we conducted a 15-minute, internet-based survey of representatives in state Medicaid agencies. In total, 47 Medicaid Agencies participated in the survey.  We collected data on state Medicaid benefits for 11 services: short-term and long-term residential treatment, detoxification, recovery services, individual, group and intensive outpatient therapy, injectable and oral naltrexone, buprenorphine, and methadone. To examine treatment organizations’ acceptance of Medicaid, we used data from the (2013-2014) of the National Drug Abuse Treatment System Survey (NDATSS), a longitudinal study of SUD treatment organizations  in the United States (n=635). We created a summative measure of the generosity of SUD treatment benefits using states’ responses regarding whether they covered each service, and if so, whether they imposed service utilization limits. We used a random effects regression model to estimate the association between the generosity of benefits and Medicaid acceptance by SUD organizations, controlling for other state-, organization- and community-level factors.

Results: The vast majority of states cover group, individual and intensive outpatient services and detoxification (over 40 states), while fewer  states cover long-term residential and recovery support services (less than 25). The majority of states impose some limits on at least some of their covered services, but the degree to which states impose limits varies by service ranging from almost all the states covering buprenorphine services imposing limits to only a third of those states covering recovery services imposing limits. The generosity of state Medicaid agency benefits for SUD services was significantly and positively related to programs’ acceptance of Medicaid (OR: 1.24, 95% CI: 1.05, 1.46).

Conclusion and Implications:  Because states have significant flexibility, Medicaid coverage of SUD services and the extent to which states restrict coverage through copays, pre-authorization and annual maximums varies substantially. Moreover, states’ benefits decisions were strongly correlated with SUD treatment organizations’ willingness to serve Medicaid patients. These findings suggest states’ benefits decisions may have important implications for SUD service access. It is crucially important that future research seeks to understand how Medicaid enrollees are faring under these drastically different SUD benefit designs.